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1.  Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care 
Critical Care  2000;4(5):302-308.
The respiratory effects of dexmedetomidine were retrospectively examined in 33 postsurgical patients involved in a randomised, placebo-controlled trial after extubation in the intensive care unit (ICU). Morphine requirements were reduced by over 50% in patients receiving dexmedetomidine. There were no differences in respiratory rates, oxygen saturations, arterial pH and arterial partial carbon dioxide tension (PaCO2) between the groups. Interestingly the arterial partial oxygen tension (PaO2) : fractional inspired oxygen (FIO2) ratios were statistically significantly higher in the dexmedetomidine group. Dexmedetomidine provides important postsurgical analgesia and appears to have no clinically important adverse effects on respiration in the surgical patient who requires intensive care.
The α2-agonist dexmedetomidine is a new class of sedative drug that is being investigated for use in ICU settings. It is an effective agent for the management of sedation and analgesia after cardiac, general, orthopaedic, head and neck, oncological and vascular surgery in the ICU [1]. Cardiovascular stability was demonstrated, with significant reductions in rate-pressure product during sedation and over the extubation period.
Dexmedetomidine possesses several properties that may additionally benefit those critically ill patients who require sedation. In spontaneously breathing volunteers, intravenous dexmedetomidine caused marked sedation with only mild reductions in resting ventilation at higher doses [2]. Dexmedetomidine reduces the haemodynamic response to intubation and extubation [3,4,5] and attenuates the stress response to surgery [6], as a result of the α2-mediated reduction in sympathetic tone. Therefore, it should be possible to continue sedation with dexmedetomidine over the stressful extubation period without concerns over respiratory depression, while ensuring that haemodynamic stability is preserved.
The present study is a retrospective analysis of the respiratory response to dexmedetomidine in 33 postsurgical patients (who were involved in a randomized, double-blind, placebo-controlled trial [1]) after extubation in the ICU.
Patients who participated in the present study were admitted after surgery to our general or cardiothoracic ICUs, and were expected to receive at least 6 h of postsurgical sedation and artificial ventilation.
On arrival in the ICU after surgery, patients were randomized to receive either dexmedetomidine or placebo (normal saline) with rescue sedation and analgesia being provided, only if clinically needed, with midazolam and morphine boluses, respectively. Sedation was titrated to maintain a Ramsay Sedation Score [7] of 3 or greater while the patients were intubated, and infusions of study drug were continued for a maximum of 6 h after extubation to achieve a Ramsay Sedation Score of 2 or greater.
The patients were intubated and ventilated with oxygen-enriched air to attain acceptable arterial blood gases, and extubation occurred when clinically indicated. All patients received supplemental oxygen after extubation, which was delivered by a fixed performance device. Assessment of pain was by direct communication with the patient.
Results are expressed as mean ± standard deviation unless otherwise stated. Patient characteristics, operative details and morphine usage were analyzed using the Mann-Whitney U-test. Statistical differences for respiratory measurements between the two groups were determined using analysis of variance for repeated measures, with the Bonferroni test for post hoc comparisons.
Of the 40 patients who participated in the study, seven patients could not be included in the analysis of respiratory function because they did not receive a study drug infusion after extubation. Consequently, data from 33 patients are used in the analysis of respiratory function; 16 received dexmedetomidine and 17 placebo. Inadequate arterial blood gas analysis was available in five patients (two from the dexmedetomidine group, and three from the placebo group). There were no significant differences in patient characteristics and operative details between the groups.
Requirements for morphine were reduced by more than 50% in patients receiving dexmedetomidine when compared with placebo after extubation (0.003 ± 0.004 vs 0.008 ± 0.006 mg/kg per h; P= 0.040).
There were no statistically significant differences between placebo and dexmedetomidine for oxygen saturations measured by pulse oximetry (P= 0.26), respiratory rate (P= 0.16; Fig. 1), arterial pH (P= 0.77) and PaCO2 (P= 0.75; Fig. 2) for the 6 h after extubation.
The dexmedetomidine group showed significantly higher PaO2: FIO2 ratios throughout the 6-h intubation (P= 0.036) and extubation (P= 0.037) periods (Fig. 3). There were no adverse respiratory events seen in either the dexmedetomidine or placebo group.
Respiratory rate for the 6-h periods before and after extubation. (Filled circle) Dexmedetomidine; (Empty circle) placebo. Values are expressed as mean ± standard deviation.
PaCO2 (PCO2) for the 6-h periods before and after extubation, and baseline values (B) on admission to ICU immediately after surgery. (Filled circle) Dexmedetomidine; (Empty circle) placebo. Values are expressed as mean ± standard deviation.
PaO2 : FIO2 ratio for the 6-h periods before and after extubation, and baseline values (B) on admission to ICU immediately after surgery. (Filled circle) Dexmedetomidine; (Empty circle) placebo. Values are expressed as mean ± standard deviation.
Lack of respiratory depression in patients sedated with α2-adrenoceptor agonists was first reported by Maxwell [8] in a study investigating the respiratory effects of clonidine. However, more recent data suggests that clonidine may cause mild respiratory depression in humans [9], and α2-adrenoceptor agonists are well known to produce profound intraoperative hypoxaemia in sheep [10,11]. The effects of dexmedetomidine on other ventilation parameters also appear to be species specific [12].
Belleville et al [2] investigated the ventilatory effects of a 2-min intravenous infusion of dexmedetomidine on human volunteers. According to those investigators, minute ventilation and arterial PaCO2 were mildly decreased and increased, respectively. There was a rightward shift and depression of the hypercapnic response with infusions of 1.0 and 2.0 μg/kg.
Previous studies that investigated the respiratory effects of dexmedetomidine have only been performed in healthy human volunteers, who have received either single intramuscular injections or short (= 10 min) intravenous infusions of dexmedetomidine. It is therefore reassuring that no deleterious clinical effects on respiration and gas exchange were seen in the patients we studied, who were receiving long-term infusions. However, there are important limitations to the present results. No dose/response curve for dexmedetomidine can be formulated from the data, and further investigation is probably ethically difficult to achieve in the spontaneously ventilating intensive care patient. We also have no data on the ventilatory responses to hypercapnia and hypoxia, which would also be difficult to examine practically and ethically. The placebo group received more than twice as much morphine as patients receiving dexmedetomidine infusions after extubation, but there were no differences in respiratory rate or PaCO2 between the groups. We can not therefore determine from this study whether dexmedetomidine has any benefits over morphine from a respiratory perspective.
There were no differences in oxygen saturations between the groups because the administered oxygen concentration was adjusted to maintain satisfactory gas exchange. Interestingly, however, there were statistically significant higher PaO2 : FIO2 ratios in the dexmedetomidine group. This ratio allows for the variation in administered oxygen to patients during the study period, and gives some clinical indication of alveolar gas exchange. However, this variable was not a primary outcome variable for the present study, and may represent a type 1 error, although post hoc analysis reveals that the data have 80% power to detect a significant difference (α value 0.05). Further studies are obviously required.
Sedation continued over the extubation period, has been shown to reduce haemodynamic disturbances and myocardial ischaemia [13]. We have previously shown [1] that dexmedetomidine provides cardiovascular stability, with a reduction in rate-pressure product over the extubation period. A sedative agent that has analgesic properties, minimal effects on respiration and offers ischaemia protection would have enormous potential in the ICU. Dexmedetomidine may fulfill all of these roles, but at present we can only conclude that dexmedetomidine has no deleterious clinical effects on respiration when used in doses that are sufficient to provide adequate sedation and effective analgesia in the surgical population requiring intensive care.
PMCID: PMC29047  PMID: 11056756
α2-Adrenoceptor agonist; analgesia; dexmedetomidine; intensive care; postoperative; respiratory; sedation
2.  Does nasal oxygen reduce the cardiorespiratory problems experienced by elderly patients undergoing endoscopic retrograde cholangiopancreatography? 
Gut  1992;33(7):973-975.
Elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) have an increased risk of sedation related complications during the procedure. To determine whether nasal oxygen supplementation (2 l/min) reduces these risks, half of 66 patients aged over 60 undergoing ERCP using minimal midazolam sedation alone were randomised to receive nasal oxygen. The arterial oxygen saturation and pulse rate of all patients were monitored by pulse oximetry before and during the procedure. Only three patients in the oxygen supplemented group (n = 33) required any form of intervention for hypoxia compared with six in the control group (n = 33). Comparison of mean arterial oxygen saturation between the groups showed significantly higher levels in the nasal oxygen group throughout the procedure. Pulse rate comparisons showed no significant difference from control group values, both groups had short periods of significant tachycardia. We conclude that minimal sedation with midazolam alone still produces hypoxia during ERCP in a substantial number of elderly patients. Nasal oxygen supplementation increases the level of patient oxygenation and reduces the need for intervention, but does not reduce tachycardia in the elderly patient. Because hyoscine may be a significant factor contributing to the tachycardia, sparing rather than routine use of this agent is advisable.
PMCID: PMC1379416  PMID: 1644341
3.  Carbon dioxide accumulation during analgosedated colonoscopy: Comparison of propofol and midazolam 
AIM: To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol.
METHODS: Consecutive patients undergoing routine colonoscopy were randomly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme. All patients received 4 μg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen. Oxygen saturation (SpO2) was measured by pulse oximetry (POX), and capnography (PcCO2) was continuously measured using a combined dedicated sensor at the ear lobe. Instances of apnea resulting in measures such as stimulation of the patient, a chin lift, a mask maneuver, or withholding of sedation were recorded. PcCO2 values (as a parameter of sedation-induced hypoventilation) were compared between groups at the following distinct time points: baseline, maximal rise, termination of the procedure and 5 min after termination of the procedure. The number of patients in both study groups who regained baseline PcCO2 values (± 1.5 mmHg) five minutes after the procedure was determined.
RESULTS: A total of 97 patients entered this study. The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems. Therefore, 83 patients (mean age 62 ± 13 years) were successfully randomized to receive propofol (n = 42) or midazolam (n = 41) for sedation. Most of the patients were classified as American Society of Anesthesiologists (ASA) II [16 (38%) in the midazolam group and 15 (32%) in the propofol group] and ASA III [14 (33%) and 13 (32%) in the midazolam and propofol groups, respectively]. A mean dose of 5 (4-7) mg of IV midazolam and 131 (70-260) mg of IV propofol was used during the procedure in the corresponding study arms. The mean SpO2 at baseline (%) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group. No cases of hypoxemia (SpO2 < 85%) or apnea were recorded. However, an increase in PcCO2 that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone. The mean interval between the initiation of sedation and the time when the PcCO2 value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol. The mean maximal rise was similar for both drugs: 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol. Five minutes after the end of the procedure, the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam (0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg, P = 0.0000169), and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg (32 of 41 vs 12 of 42, P = 0.0004).
CONCLUSION: A significantly higher number of patients sedated with propofol had normalized PcCO2 values five minutes after sedation when compared with patients sedated with midazolam.
PMCID: PMC3471107  PMID: 23082055
Colonoscopy; Deep sedation; Propofol; Hypoventilation; Blood gas monitoring; Transcutaneous
4.  241 Nasal Cytology is Important in the Classification of Patients with Allergic and Non-Allergic Rhinitis 
The purpose of the study is the classification and clinical characterization of patients with allergic rhinitis and non-allergic and differentiate the presence of eosinophils and neutrophils in nasal cytology.
Prospective study of 405 patients with chronic symptoms of sneezes, pruritus, nasal congestion and rhinorrhea were evaluated by clinical examination, skin prick test and nasal cytology. Patients with diseases and/or treatments that could alter the outcome of these tests were excluded.
405 patients from 3 to 80 years were evaluated; 248 female patients (61%) and 157 males (39%). The sample was divided into 2 groups according to skin prick tests: allergic 270 (67%), 135 non-allergic (33%). The mean age of onset of symptoms was 14.27 and 23.47 years in allergic and nonallergic respectively. Nasal symptoms (nasal congestion, sneezes/pruritus, rhinorrhea, postnasal secretion) and signs (turbinates color and edema, secretion and oropharynx redness) were accessed using scores from 0 to 3, ranging from 0 to 24. In the allergic group the mean total nasal symptoms and signs scores were 6.64 and 4.66, while in non-allergic were 5.67 and 3.52. Allergic patients had an average 27.82% of eosinophils and 64.09% of neutrophils in nasal smears, whereas non-allergic patients 8.38% and 85.30%. Using skin prick test and nasal cytology we were able to diagnose allergic rhinitis in 69.6% (208) of the patients. 20.7% (62) had neutrophilic non-allergic rhinitis (NARNA) and 9.7% (29) non-allergic rhinitis with eosinophilia syndrome (NARES). No idiopathic rhinitis patients were found.
The frequencies of the types of rhinitis were: allergic rhinitis 69.6%, RENA 9.7%, NARNA 20.7% and idiopathic rhinitis 0%. Despite the fact that each sub group of nonallergic rhinitis has particularities, in allergic rhinitis we found early onset of complaints, signs and symptoms more intense and a greater number of eosinophils, compared with the nonallergic patients.
PMCID: PMC3512858
5.  Minimally invasive application of botulinum toxin A in patients with idiopathic rhinitis 
Head & Face Medicine  2009;5:18.
Nasal hypersecretion due to idiopathic rhinitis can often not be treated sufficiently by conventional medication. Botulinum toxin A (BTA) has been injected into the nasal mucosa in patients with nasal hypersecretion with a reduction of rhinorrhea lasting for about 4 to 8 weeks. Since the nasal mucosa is well supplied with glands and vessels, the aim of this study was to find out if the distribution of BTA in the nasal mucosa and a reduction of nasal hypersecretion can also be reached by a minimally invasive application by sponges without an injection.
Patients were randomly divided into two groups. The effect of BTA (group A, C, D) or saline as placebo (group B) was investigated in 20 patients with idiopathic rhinitis by applying it with a sponge soaked with BTA (40 units each nostril) or saline. Subgroups C and D contained these patients of group A and B who did not improve in symptoms one week after the original treatment (either BTA or saline) who then received the alternative medication. Changes of symptoms (rhinorrhea, nasal obstruction) were scored by the patients in a four point scale and counted (consumption of tissues, sneezing) in a diary. The patients were followed up weeks 1, 2, 4, 8 and 12.
There was a clear reduction of the amount of secretion in group A compared to group B, C and D. This did not correlate with the tissue consumption, which was comparably reduced in group A and B, but reduced less in group C and D. Sneezing was clearly reduced in group A but comparably unchanged in group B and C and increased in group D. Nasal congestion remained unchanged.
In some patients with therapy-resistant idiopathic rhinitis BTA applied with a sponge is a long-lasting and minimal invasive therapy to reduce nasal hypersecretion.
PMCID: PMC2770996  PMID: 19835591
6.  Deep sedation during gastrointestinal endoscopy: Propofol-fentanyl and midazolam-fentanyl regimens 
AIM: To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy.
METHODS: After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer’s assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ2 test, measurement of analysis of variance, and the κ statistic.
RESULTS: The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination.
CONCLUSION: Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.
PMCID: PMC3683682  PMID: 23801836
Endoscopy; Deep sedation; Anesthetic administration; Anesthetic dose; Adverse effects
7.  The Effect of Combined Medical Treatment on Quality of Life in Persistent Allergic Rhinitis 
Allergic rhinitis may significantly affect the patients’ quality of life. The aim of this study was to compare the effects of nasal steroids alone, to nasal steroids plus Levocetirizine or Montelukast, on quality of life in persistent allergic rhinitis. This is a prospective, randomized study and included 56 patients with moderate to severe persistent allergic rhinitis. All patients had house dust mite allergy on skin prick test and we divided the patients into three groups. 1 month long medical treatment was; topical Mometasone furoate 200 mcg/day in the first group (n:14), Mometasone furoate 200 mcg/day plus oral Levocetirizine 5 mg/day in the second group (n:21), and Mometasone furoate 200 mcg/day plus oral Montelukast 10 mg/day in the third group (n:21). We evaluated the patients before treatment and at the first month after treatment with mini rhinoconjunctivitis quality of life questionnaire (miniRQLQ) and nasal symptom scores. In the first group nasal symptom and mini RQLQ scores were not improved but in second and third group, both scores were improved significantly (p < 0.05). Nasal obstruction symptom score was better in the third group after treatment (p < 0.01), but other nasal symptom scores (rhinorrhea, sneezing and nasal itching) were better in the second group (For each symptom p < 0.05). Improvement of quality of life scores in the second group were better than the third group (p < 0.05). In persistent allergic rhinitis, combination of levocetirizine or montelukast to nasal steroids was better than the topical mometasone furoate alone in terms of quality of life.
PMCID: PMC3738792  PMID: 24427672
Allergic rhinitis; Medical treatment; Quality of life; Nasal steroid; Levocetirizine; Montelukast
8.  Comparison of nasal Midazolam with Ketamine versus nasal Midazolam as a premedication in children 
Saudi Journal of Anaesthesia  2014;8(1):17-21.
This study was done to compare effects of intranasal midazolam and intranasal midazolam with ketamine for premedication of children aged 1-12 yrs undergoing intermediate and major surgeries.
Midazolam and Ketamine have already been used as premedicants in children. Our aim was to find out advantage of combination of midazolam with ketamine over midazolam by nasal route.
Sixty children of age group 1-12 yrs of American Society of Anesthesiologists (ASA) grade 1 and 2 were selected. Group A- midazolam (0.2 mg/kg), Group B- midazolam (0.15 mg/kg + ketamine 1 mg/kg). Both groups received drug intranasally 30 min before surgery in recovery room with monitored anesthesia care. Onset of sedation, sedation score, emotional reaction, intravenous cannula acceptance, and mask acceptance were studied.
Statistical Analysis:
Unpaired t test and chi square test.
Sedation score, anxiolysis, attitude, reaction to intravenous cannulation, face mask acceptance, and emotional reaction were significantly better in midazolam with ketamine group. Intra operatively, in both groups, pulse rate, oxygen saturation, and respiratory rate had no significant difference; also, post operatively, no significant difference was observed in above parameters, post operative analgesia was significantly better in midazolam with ketamine group.
Intra nasal premedication allows rapid and predictable sedation in children. Midazolam as well as combination of Midazolam with ketamine gives good level of sedation and comfort. But quality of sedation, analgesia, and comfort is significantly better in midazolam with ketamine group. No significant side effects were observed in both groups.
PMCID: PMC3950446  PMID: 24665234
Intranasal; Ketamine; midazolam; pediatric anesthesia
9.  Morning and evening efficacy evaluation of rupatadine (10 and 20 mg), compared with cetirizine 10 mg in perennial allergic rhinitis: a randomized, double-blind, placebo-controlled trial 
A circadian rhythm of symptoms has been reported in allergic rhinitis (AR). Severity of all major symptoms of AR, including runny nose, sneezing, and nasal congestion, is typically at its peak in the morning. The objective of this study was to explore the efficacy of the antihistamine and platelet activating factor (PAF) antagonist rupatadine in the morning and evening and to evaluate whether rupatadine provides effective symptom relief throughout the 24-hour dosing interval.
A total of 308 patients ≥18 years of age with PAR was randomly assigned to once-daily rupatadine 10 mg, rupatadine 20 mg, or cetirizine 10 mg for 4 weeks in a placebo-controlled, double-blind study. The main outcome was the morning/evening reflective total symptom score (5TSS) over the treatment period. Secondary endpoints included morning/evening reflective nasal total symptom score (4NTSS), individual symptoms, Pdmax1 as percentage of days with daily severest symptom score ≤1, and subject/investigator evaluation of therapeutic response.
All active groups were significantly more effective than placebo in improving morning and evening evaluations of 5TSS (P < 0.001) and 4NTSS (P < 0.001) at 2 or 4 weeks. At morning evaluation, there was a significant reduction from baseline for 5TSS with rupatadine 10 mg (−36.8%, P < 0.01) and 20 mg (−46.3%, P < 0.01) compared with placebo. Similarly, 4NTSS was reduced significantly more with rupatadine 10 mg (−34%, P < 0.05) and 20 mg (−41%, P < 0.01) compared with placebo. In the cetirizine 10 mg group, the reduction was −32.7% and −32.2% for 5TSS and 4NTSS, respectively, but this reduction was not significant compared with placebo. The percentage reduction was greater at evening than at morning evaluation. 5TSS reduction with rupatadine 10 mg (−40.7%, P < 0.05) and 20 mg (−49.9%, P < 0.01) and cetirizine 10 mg (−40.1%, P < 0.05) was significantly better than with placebo. 4NTSS values for active groups were also significantly improved versus placebo. When individual symptoms were assessed, statistically significant differences for rhinorrhea (P < 0.01), nasal itching (P < 0.01), and sneezing (P < 0.01) were shown in all active groups compared with placebo at morning and evening evaluations. Pdmax1 index was significantly improved for all active groups and the overall efficacy assessed by patients or investigators showed a significant improvement (P < 0.01) versus placebo at 2 and 4 weeks. The incidence of somnolence was significantly greater in all active groups versus placebo.
The sustained 24-hour action of rupatadine 10 mg provides an effective control of morning and evening symptoms in patients with PAR treated for up to 4 weeks.
PMCID: PMC3116790  PMID: 21698213
allergic rhinitis; circadian rhythm; morning and evening symptoms; antihistamines; rupatadine
10.  Management of Rhinitis: Allergic and Non-Allergic 
Rhinitis is a global problem and is defined as the presence of at least one of the following: congestion, rhinorrhea, sneezing, nasal itching, and nasal obstruction. The two major classifications are allergic and nonallergic rhinitis (NAR). Allergic rhinitis occurs when an allergen is the trigger for the nasal symptoms. NAR is when obstruction and rhinorrhea occurs in relation to nonallergic, noninfectious triggers such as change in the weather, exposure to caustic odors or cigarette smoke, barometric pressure differences, etc. There is a lack of concomitant allergic disease, determined by negative skin prick test for relevant allergens and/or negative allergen-specific antibody tests. Both are highly prevalent diseases that have a significant economic burden on society and negative impact on patient quality of life. Treatment of allergic rhinitis includes allergen avoidance, antihistamines (oral and intranasal), intranasal corticosteroids, intranasal cromones, leukotriene receptor antagonists, and immunotherapy. Occasional systemic corticosteroids and decongestants (oral and topical) are also used. NAR has 8 major subtypes which includes nonallergic rhinopathy (previously known as vasomotor rhinitis), nonallergic rhinitis with eosinophilia, atrophic rhinitis, senile rhinitis, gustatory rhinitis, drug-induced rhinitis, hormonal-induced rhinitis, and cerebral spinal fluid leak. The mainstay of treatment for NAR are intranasal corticosteroids. Topical antihistamines have also been found to be efficacious. Topical anticholinergics such as ipratropium bromide (0.03%) nasal spray are effective in treating rhinorrhea symptoms. Adjunct therapy includes decongestants and nasal saline. Investigational therapies in the treatment of NAR discussed include capsaicin, silver nitrate, and acupuncture.
PMCID: PMC3121056  PMID: 21738880
Allergic rhinitis; nonallergic rhinitis; intranasal corticosteroids; immunotherapy; intranasal antihistamines; oral antihistamines
11.  Acupuncture for persistent allergic rhinitis: a multi-centre, randomised, controlled trial protocol 
Trials  2009;10:54.
Allergic rhinitis is one of the most common health complaints worldwide. Complementary and alternative medical approaches have been employed to relieve allergic rhinitis symptoms and to avoid the side effects of conventional medication. Acupuncture has been widely used to treat patients with allergic rhinitis, but the available evidence of its effectiveness is insufficient. Our objective is to evaluate the effectiveness of acupuncture in patients in Korea and China with persistent allergic rhinitis compared to sham acupuncture treatment or waitlist control.
This study consists of a multi-centre (two centres in Korea and two centres in China), randomised, controlled trial with three parallel arms (active acupuncture, sham acupuncture, and waitlist group). The active acupuncture and sham acupuncture groups will receive real or sham acupuncture treatment, respectively, three times per week for a total of 12 sessions over four weeks. Post-treatment follow-up will be performed a month later to complement these 12 acupuncture sessions. Participants in the waitlist group will not receive real or sham acupuncture treatments during this period but will only be required to keep recording their symptoms in a daily diary. After four weeks, the same treatment given to the active acupuncture group will be provided to the waitlist group.
This trial will provide evidence for the effectiveness of acupuncture as a treatment for persistent allergic rhinitis. The primary outcome between groups is a change in the self-reported total nasal symptom score (i.e., nasal obstruction, rhinorrhea, sneezing, and itching) from baseline at the fourth week. Secondary outcome measures include the Rhinitis Quality of Life Questionnaire score and total non-nasal symptom score (i.e., headache, itching, pain, eye-dropping). The quantity of conventional relief medication used during the follow-up period is another secondary outcome measure.
Trial registration
Current Controlled Trials ISRCTN90807007
PMCID: PMC2715403  PMID: 19602250
12.  Therapeutic Effects of Fermented Red Ginseng in Allergic Rhinitis: A Randomized, Double-Blind, Placebo-Controlled Study 
Allergic rhinitis is clinically defined as a disorder of the nose induced by IgE mediated inflammation after allergen exposure of the nasal mucosa. Many reports have stated that Panax ginseng and fermented red ginseng have anti-inflammatory effects, especially against Th2-type inflammation. This study was conducted to evaluate the therapeutic effects of fermented red ginseng in allergic rhinitis.
In this 4-week, double-blind, placebo-controlled study, 59 patients with persistent perennial allergic rhinitis were randomly divided into two groups: those receiving fermented red ginseng tablets (experimental group) and those receiving placebo (control group). The primary efficacy variable was the total nasal symptom score (TNSS; rhinorrhea, sneezing, itchy nose, and nasal congestion). Secondary efficacy variables were the Rhinitis Quality of Life (RQoL) score and skin reactivity to inhalant allergens, as determined by the skin prick test.
There was no significant difference in the TNSS score and TNSS duration score between the experimental and placebo groups in weeks 1, 2, 3, or 4. For nasal congestion, fermented red ginseng was significantly effective (P<0.005), while placebo caused no change. The activity and emotion of RQoL improved markedly secondary to treatment with fermented red ginseng (P<0.05), while placebo caused no change. Additionally, fermented red ginseng reduced skin reactivity to sensitized perennial allergens (P<0.05). Fermented red ginseng was well tolerated.
Fermented red ginseng improved nasal congestion symptoms and RQoL in patients with perennial allergic rhinitis.
PMCID: PMC3062788  PMID: 21461249
Allergic rhinitis; alternative medicine; fermented ginseng; ginsenoside
13.  Comparison between the recovery time of alfentanil and fentanyl in balanced propofol sedation for gastrointestinal and colonoscopy: a prospective, randomized study 
BMC Gastroenterology  2012;12:164.
There is increasing interest in balanced propofol sedation (BPS) titrated to moderate sedation (conscious sedation) for endoscopic procedures. However, few controlled studies on BPS targeted to deep sedation for diagnostic endoscopy were found. Alfentanil, a rapid and short-acting synthetic analog of fentanyl, appears to offer clinically significant advantages over fentanyl during outpatient anesthesia.
It is reasonable to hypothesize that low dose of alfentanil used in BPS might also result in more rapid recovery as compared with fentanyl.
A prospective, randomized and double-blinded clinical trial of alfentanil, midazolam and propofol versus fentanyl, midazolam and propofol in 272 outpatients undergoing diagnostic esophagogastroduodenal endoscopy (EGD) and colonoscopy for health examination were enrolled. Randomization was achieved by using the computer-generated random sequence. Each combination regimen was titrated to deep sedation. The recovery time, patient satisfaction, safety and the efficacy and cost benefit between groups were compared.
260 participants were analyzed, 129 in alfentanil group and 131 in fentanyl group. There is no significant difference in sex, age, body weight, BMI and ASA distribution between two groups. Also, there is no significant difference in recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between two groups. Though deep sedation was targeted, all cardiopulmonary complications were minor and transient (10.8%, 28/260). No serious adverse events including the use of flumazenil, assisted ventilation, permanent injury or death, and temporary or permanent interruption of procedure were found in both groups. However, fentanyl is New Taiwan Dollar (NT$) 103 (approximate US$ 4) cheaper than alfentanil, leading to a significant difference in total cost between two groups.
This randomized, double-blinded clinical trial showed that there is no significant difference in the recovery time, satisfaction score from patients, propofol consumption, awake time from sedation, and sedation-related cardiopulmonary complications between the two most common sedation regimens for EGD and colonoscopy in our hospital. However, fentanyl is NT$103 (US$ 4) cheaper than alfentanil in each case.
Trial registration
Institutional Review Board of Buddhist Tzu Chi General Hospital (IRB097-18) and Chinese Clinical Trial Registry (ChiCTR-TRC-12002575)
PMCID: PMC3607964  PMID: 23170921
Balanced propofol sedation; Alfentanil; Fentanyl; Deep sedation; Diagnostic endoscopy; Cost benefit
14.  A direct comparison of efficacy between desloratadine and rupatadine in seasonal allergic rhinoconjunctivitis: a randomized, double-blind, placebo-controlled study 
H1-antihistamines are recommended as the first-line symptomatic treatment of allergic rhinitis. The objective of this study was to evaluate the effects of rupatadine (RUP) versus desloratadine (DES) in subjects with seasonal allergic rhinitis (SAR).
To assess the efficacy and safety of RUP in SAR in comparison with placebo (PL) and DES. A randomized, double-blind, multicenter, international, and PL-controlled study was carried out. The main selection criteria included SAR patients over 12 years old with a positive prick test to a relevant seasonal allergen for the geographic area. Symptomatic patients at screening with a nasal symptom sum score of ≥6 points (nasal discharge, nasal obstruction, sneezing, and nasal pruritus), a non-nasal score of ≥3 points (ocular pruritus, ocular redness, and tearing eyes), and a rhinorrhea score of ≥2 points with laboratory test results and electrocardiography within acceptable limits were included in the study. Change from baseline in the total symptom-score (T7SS) over the 4-week treatment period (reflective evaluation) was considered the primary efficacy variable. Secondary efficacy measures included total nasal symptom score (T4NSS) and conjunctival symptom score (T3NNSS), both of which are reflective and instantaneous evaluations. Furthermore questions related to quality of life (eg, sleep disturbances or impairment of daily activities) have also been evaluated. Safety was assessed according to adverse events reported, as well as laboratory and electrocardiography controls.
A total of 379 patients were randomized, of which 356 were included and allocated to PL (n = 122), RUP (n = 117), or DES (n = 117). Mean change of T7SS over the 4-week treatment period was significantly reduced in the RUP (–46.1%, P = 0.03) and DES (–48.9%, P = 0.01) groups, compared with PL. Similarly, RUP and DES were comparable and significantly superior to PL for all secondary endpoints, including nasal and conjunctival symptoms and patients’ and investigator’s overall clinical opinions. Symptom score evaluation (both reflective and instantaneous evaluations) throughout the treatment period showed a progressive and maintained significant improvement with both treatments at day 7 (P = 0.01), day 14 (P = 0.007), and day 21 (P = 0.01) in comparison with PL. Adverse events were scarce and were similar in both treatment groups. Electrocardiography (QTc) and lab test results did not show any relevant findings
RUP is a very good choice for SAR due to its contribution to the improvement of nasal (including obstruction) and non-nasal symptoms to a similar degree as DES.
PMCID: PMC3582315  PMID: 23459334
allergic rhinitis; seasonal; H1-antihistamines; rupatadine; desloratadine
15.  Changes of Alpha1-Antitrypsin Levels in Allergen-induced Nasal Inflammation 
Alpha1-antitrypsin (AAT) is the main inhibitor of human neutrophil elastase, and plays a role in counteracting the tissue damage caused by elastase in local inflammatory conditions. The study evaluated the involvement of AAT in nasal allergic inflammation.
Forty subjects with mono-sensitization to Dermatophagoides pteronyssinus (Dpt) were enrolled. Twenty allergic rhinitis patients frequently complained of nasal symptoms such as rhinorrhea, stuffiness, sneezing, and showed positive responses to the nasal provocation test (NPT) with Dpt (Group I). The other 20 asymptomatic patients showed sensitization to Dpt but negative NPT (Group II). The levels of AAT, eosinophil cationic protein (ECP), and Dpt-specific IgA antibodies were measured in the nasal lavage fluids (NLFs), collected at baseline, 10 minutes, 30 minutes, 3 hours, and 6 hours after the NPT. Nasal mucosa AAT expression was evaluated with immunohistochemical staining from Group I and Group II.
At baseline, only the Dpt-specific IgA level was significantly increased in the NLFs of Group I compared with Group II, while ECP and AAT levels were not significantly different between two groups. After Dpt provocation, AAT, ECP, and Dpt-specific IgA levels were significantly increased in the NLFs of Group I during the early and late responses. The protein expression level of AAT was mostly found in the infiltrating inflammatory cells of the nasal mucosa, which was significantly increased in Group I compared to Group II.
The increment of AAT showed a close relationship with the activation of eosinophils induced by allergen-specific IgA in the NLFs of patients with allergic rhinitis after allergen stimulation. These findings implicate AAT in allergen-induced nasal inflammation.
PMCID: PMC3062225  PMID: 21461061
Alpha1-antitrypsin; Allergic rhinitis; Eosinophil cationic protein; IgA; Nasal lavage fluid
16.  Use of nitric oxide inhalation in chronic obstructive pulmonary disease 
Thorax  2000;55(2):109-113.
BACKGROUND—Inhalation of nitric oxide with oxygen could be a promising treatment in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension. However, the current methods of delivery of NO are cumbersome and unsuitable for long term use. The present study was undertaken to investigate the safety and efficacy of a mixture of nitric oxide (NO) and oxygen administered via a nasal cannula for 24 hours in patients with oxygen dependent COPD.
METHODS—Twenty five parts per million (ppm) of NO was administered by inhalation combined with supplemental oxygen at a flow rate of 2 l/min via a nasal cannula for 24 hours to 11 ambulatory men with stable, oxygen dependent COPD. Room air with supplemental oxygen at 2 l/min was administered in an identical manner for another 24 hours as control therapy in a randomised, double blind, crossover fashion to all patients. Pulmonary function tests, exercise tolerance, dyspnoea grade, and lung volumes were measured at baseline, 24, and 48 hours. Pulmonary artery pressure (PAP), cardiac output (CO), pulmonary vascular resistance (PVR), arterial blood gas tensions, and minute ventilation were measured at baseline, after 30 minutes and 24 hours of breathing NO and oxygen. Venous admixture ratio (Qs/Qt) and dead space ratio (Vd/Vt) were also calculated. Concentrations of nitrogen dioxide (NO2) and NO in the inhaled and ambient air were monitored continuously. Differences in pulmonary function, arterial blood gas tensions, pulmonary haemodynamics, exercise tolerance, and dyspnoea between oxygen and NO breathing periods were analysed for significance using paired t tests.
RESULTS—A significant (p<0.05) fall was observed in PVR (183.1 (116.05) and 137.2 (108.4) before and after breathing NO for 24 hours, respectively) with NO administration without significant changes in symptoms, pulmonary function, arterial oxygen tension, or exercise tolerance.
CONCLUSIONS—NO at a concentration of 25 ppm blended with oxygen can be safely administered by nasal cannula for 24 hours without significant adverse effects and lowers PVR in stable patients with COPD receiving long term oxygen therapy.

PMCID: PMC1745679  PMID: 10639526
17.  180 Selecting Primal Therapy Appropriate for the Type of Pollinosis—Topic-J Study 
The World Allergy Organization Journal  2012;5(Suppl 2):S76-S77.
In Japanese Guideline for Allergic Rhinitis, drugs for treatment after the start of pollen dispersal are recommended for each type of pollinosis, but drugs for primal therapy are not categorized by the type of pollinosis. We examined the adequacy of different drugs for primal therapy on each type of pollinosis.
Patients with pollinosis attending 11 otorhinolaryngology clinics in Tokyo during part of pollen season (February 18–26) were enrolled and assigned to either an anti-leukotriene agent (pranlukast) or an antihistamine based on their symptoms in the previous year. During 3 months of treatment, symptoms and quality of life (QOL) were investigated by a mail questionnaire at 7 time points (at the start of treatment, and between March 1 and May 15).
Of 150 patients with pollinosis who were registered, analysis was conducted on 144 patients (62 receiving anti-leukotriene therapy and 82 receiving antihistamine therapy), excluding those with incomplete questionnaires. In both groups, scores for symptoms of pollinosis and QOL were low, suggesting that both drugs were effective considering the high pollen levels season (5–9 times higher than the previous year). After defining types of pollinosis by the severity of symptoms (sneezing, rhinorrhea, or nasal blockage), stratified analysis was conducted. This showed that antihistamine therapy was effective for the sneezing/rhinorrhea type and anti-leukotriene therapy was effective for the nasal blockage type, with no difference between the 2 drugs the combined type. For the nasal blockage type, symptoms and QOL improved faster with anti-leukotriene than antihistamine therapy from the peak to the end of the pollen season. No adverse effects were observed.
When either an anti-leukotriene (pranlukast) or an antihistamine was used for primal therapy of pollinosis, both drugs improved pollinosis symptoms and QOL. Stratified analysis showed that the antihistamine was more effective for the sneezing/rhinorrhea type and the anti-leukotriene was more effective for the nasal blockage type, with no difference in effectiveness for the combined type. Therefore, appropriate drugs for the type of pollinosis should be selected for primal therapy.
PMCID: PMC3513028
18.  236 H1 Antihistamines Influence on Pro-inflammatory Cytokines Level in Patients With Allergic Rhinitis 
The World Allergy Organization Journal  2012;5(Suppl 2):S94-S95.
The aim of the study is to evaluate the effect of H1 antihistamines on symptoms and pro-inflammatory cytokines plasmatic level in patients with persistent allergic rhinitis (PAR), after 4 weeks treatment, during continuous exposure to allergens.
79 patients, mean age 30.44 ± 9.90 years, diagnosed with PAR were included in the study, divided into 2 groups: 39 patients were under treatment with Desloratadine 5 mg/day and 40 patients received Levocetirizine 5 mg/day for 4 weeks. The patients were evaluated before and after the treatment, regarding rhinitis symptoms (sneezing, rhinorrhea, nasal congestion, nasal and ocular itching), total symptoms score, type of sensitisation (indoor or outdoor allergens), plasmatic levels of IL-6 and IL-8. The obtained data were analised using SPSS 15 and GraphPad Prism 4 programs, using Wilcoxon Signed Rank and Mann Whitney test, with a significant P values < 0.05.
Both Desloratadine and Levocetirizine reduce total symptoms score (8.35 versus 1.97, P = 0.0001, respectively 8.67 versus 1.97, P = 0.0001), especially nasal congestion in patients with allergic rhinitis (1.76 versus 1.02, P = 0.001 and 1.72 versus 0.87, P = 0.0001). IL-6 and IL-8 have no different plasmatic level in patients with allergic rhinitis compared with the values obtained in healthy volunteers. Levocetirizine reduces plasmatic level of IL-6 (1.19 versus 1.006, P = 0.0097) and IL-8 (8.90 versus 6.90, P = 0.0003) after 4 weeks treatment, while Desloratadine has influence only IL-6 level (1.68 versus 1.36, P = 0.0038). The intergroup analysis revealed no significant difference between these 2 drugs regarding IL-6 (P = 0.36) and IL-8 (P = 0.25).
Both studied H1 antihistamines present anti-inflammatory effect in patients with PAR after 4 weeks treatment.
PMCID: PMC3512911
19.  Effects of Supplemental Oxygen on Maternal and Neonatal Oxygenation in Elective Cesarean Section under Spinal Anesthesia: A Randomized Controlled Trial 
BioMed Research International  2014;2014:627028.
The use of supplemental oxygen in uncomplicated cesarean deliveries under spinal anesthesia has been thoroughly investigated during recent decades. The aim of this study was to determine the benefits for both mother and infant of administering supplemental, low-dose oxygen via a nasal cannula versus having no supplement (i.e., room air only). Healthy parturients at term undergoing elective cesarean section under spinal anesthesia were randomly allocated into two groups: an oxygen group (n = 170), who received 3 LPM oxygen via a nasal cannula; and a room-air group (n = 170), who were assigned to breathe room air. Maternal oxygen saturation was measured continuously by using pulse oximeter. The desaturation was determined by oxygen saturation <94% over 30 seconds. Umbilical cord gases and Apgar scores were collected followed delivery of the infant. All maternal desaturation events occurred in 12 parturients assigned to the room-air group. Most events were concurrent with hypotension. The umbilical venous partial pressure of oxygen was significantly higher in the oxygen group. The other blood gas measurements and Apgar scores were not significantly different between the two groups. Based on our findings, the use of supplemental oxygen could prevent maternal desaturation resulting from receiving sedation and intraoperative hypotension.
PMCID: PMC3950466  PMID: 24696860
20.  Persistent Allergic Rhinitis and the XPERT Study 
The World Allergy Organization Journal  2011;4(Suppl 3):S32-S36.
Allergic rhinitis (AR) is a chronic disease with an increasing trend in most of the Western Countries. It may significantly impair the individual quality of life (QoL) and also represents a social burden for its economic costs. Levocetirizine (XYZAL; UCB Pharma) as a second generation, nonsedating H1-antihistamine, has been shown to be clinically effective in patients with AR in different randomized controlled trials. The XPERT (XYZAL in Persistent Rhinitis Trial) is the first large, long-term clinical study involving patients with persistent rhinitis as defined by ARIA (Allergic Rhinitis and its Impact on Asthma). The XPERT was a 6-month double-blind, placebo-controlled, multicenter, multinational trial in 551 subjects. Adults with persistent rhinitis sensitized to both grass pollen and house dust mites were randomized to receive levocetirizine 5 mg/d or placebo. Two primary objectives were considered: comparison of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) overall score and Total 5 Symptoms Score (rhinorrhea, sneezing, nasal congestion, and nasal and ocular pruritus) (T5SS) between active and control group over a period of 4 weeks. As secondary endpoints, similar evaluations at 1 week and 3, 4, 5, and 6 months, summary scores for a general health status questionnaire (Medical Outcomes Survey Short Form 36), comorbidities, pharmacoeconomic and safety evaluations. Levocetirizine significantly improved both the RQLQ overall score and the T5SS from week 1 to 6 months (P < .001). Medical Outcomes Survey Short Form 36 summary scores were also improved in the group treated with levocetirizine with respect to placebo. Treatment cessation because of lack of efficacy, comorbidities, and overall costs of disease, and comorbidities per working patient per month (160.27 vs 108.18) were lower in the levocetirizine group. In conclusion, levocetirizine resulted to improve the quality of life and the symptoms related to AR and also to reduce the overall costs of the disease after 6 months treatment.
PMCID: PMC3666184  PMID: 23282334
persistent allergic rhinitis; XPERT Study; ARIA; PER; treatment
21.  Pharmacology of Nasal Medications: An Update 
Canadian Family Physician  1988;34:2706-2709.
The author of this article reviews the pharmacology of nasal medication, focusing on the indications and side-effects. The newer group of non-sedating antihistamines proves to be a useful supplement to disodium cromoglycate and the traditional antihistamines in the treatment of allergic rhinitis. The topical steroids (flunisolide and beclomethasone dipropionate) did not produce a significant incidence of adrenal suppression, mucosal atrophy, or nasal candidiasis. The anticholinergic ipatropium bromide shows promise in the treatment of rhinorrhea. The author also reviews the use of decongestants and emollients and remarks on the factors that affect patient compliance when nasal medications are prescribed.
PMCID: PMC2218146  PMID: 20469495
pharmacology; nasal medications; decongestants; patient compliance
22.  Is there any correlation between the results of skin-prick test and the severity of symptoms in allergic rhinitis? 
This study was designed to determine whether there is any correlation between results of the skin-prick test and the severity of symptoms in allergic rhinitis.
We retrospectively evaluated 150 patients with persistent or intermittent allergic rhinitis confirmed by positive skin tests and scaled from 1 to 4 according to the size of the wheal. The symptoms including sneezing, nasal obstruction, rhinorrhea, and nasal itching were ranked according to their severity (0 for no symptoms, 1 for mild, 2 for moderate, and 3 for severe). We investigated the correlation between the skin tests' positivity and symptoms score, rhinoconjunctivitis quality-of-life questionnaire (RQLQ), and visual analog scale (VAS) scores.
Of the 150 patients, 98 had persistent and 52 had intermittent allergic rhinitis. Some patients had multiple allergen sensitivity. Each skin test group was compared with respect to symptom scores, RQLQ, or VAS scores. There was no statistically significant correlation between the size of the wheal and symptoms score, RQLQ, or VAS scores. There was also no correlation between the type of allergen and symptoms score.
The skin-prick test can be applied to support the diagnosis of allergic rhinitis, but one can not predict the severity of illness by stratifying the size of the skin-prick test result.
PMCID: PMC3906524  PMID: 22391080
Allergic rhinitis; rhinoconjunctivitis quality of life; skin-prick test; symptoms score; VAS
23.  A prospective study of high dose sedation for rapid tranquilisation of acute behavioural disturbance in an acute mental health unit 
BMC Psychiatry  2013;13:225.
Acute behavioural disturbance (ABD) is a common problem in psychiatry and both physical restraint and involuntary parenteral sedation are often required to control patients. Although guidelines are available, clinical practice is often guided by experience and there is little agreement on which drugs should be first-line treatment for rapid tranquilisation. This study aimed to investigate sedation for ABD in an acute mental healthcare unit, including the effectiveness and safety of high dose sedation.
A prospective study of parenteral sedation for ABD in mental health patients was conducted from July 2010 to June 2011. Drug administration (type, dose, additional doses), time to sedation, vital signs and adverse effects were recorded. High dose parenteral sedation was defined as greater than the equivalent of 10 mg midazolam, droperidol or haloperidol (alone or in combination), compared to patients receiving 10 mg or less (normal dose). Effective sedation was defined as a fall in the sedation assessment tool score by two or a score of zero or less. Outcomes included frequency of adverse drug effects, time to sedation/tranquilisation and use of additional sedation.
Parenteral sedation was given in 171 cases. A single drug was given in 96 (56%), including droperidol (74), midazolam (19) and haloperidol (3). Effective sedation occurred in 157 patients (92%), and the median time to sedation was 20 min (Range: 5 to 100 min). The median time to sedation for 93 patients receiving high dose sedation was 20 min (5-90 min) compared to 20 min (5-100 min; p = 0.92) for 78 patients receiving normal dose sedation. Adverse effects occurred in 16 patients (9%); hypotension (14), oxygen desaturation (1), hypotension and oxygen desaturation (1). There were more adverse effects in the high dose sedation group compared to the normal dose group [11/93 (12%) vs. 5/78 (6%); p = 0.3]. Additional sedation was given in 9 of 171 patients (5%), seven in the high dose and two in the normal dose groups.
Large initial doses of sedative drugs were used for ABD in just over half of cases and additional sedation was uncommon. High dose sedation did not result in more rapid or effective sedation but was associated with more adverse effects.
PMCID: PMC3848824  PMID: 24044673
Violence; Sedation; Acute psychiatric unit; Droperidol; Benzodiazepine; Antipsychotic
24.  Higher Dosage of HIFU Treatment May Lead to Higher and Longer Efficacy for Moderate to Severe Perennial Allergic Rhinitis 
Objectives: This study was to compare the efficacies and side effects of high intensity focused ultrasound (HIFU) treatment for perennial allergic rhinitis (PAR) with regular and increased dosage.
Study design: A prospectively assembled cohort was retrospectively analyzed through visual analogue scale (VAS).
Methods: Regular dosage of HIFU treatment was applied to 56 PAR patients in group A. An increased dosage as twice as the regular one was applied to 48 patients in group B. Nasal obstruction, sneezing, rhinorrhea and rhinocnesmus, which were recognized as the four main symptoms of allergic rhinitis (AR), were evaluated before treatment, 3 months after treatment, and 1 year after treatment. The satisfaction of patients was also evaluated at 1 year postoperatively. Biopsy of the inferior turbinate and morphometric analysis were applied to 11 patients in group A and 10 in group B before HIFU treatment and 3 months after treatment.
Results: Comparing the AR symptoms before treatment, There is no statistical difference observed between group A and B (p>0.05). The four main symptoms at 3 months and 1 year after treatment were all significantly improved (p<0.01) in both group A and B. The VAS scores of AR symptoms in Group B were lower than those in Group A at the same stage after treatment, especially at 1 year after treatment (p<0.05). Comparing the results at 3 months and 1 year after treatment, a tendency of recurrence of these symptoms was observed statistically in group A (p<0.05), but not in group B (p>0.05). More cases of nasal dryness and perirhinal swelling were found in group B than those in group A (p<0.05), while all side effects were mild and temporary. Patients in group B were more satisfied than those in group A (p=0.0866 >0.05), though not statistically significant. More reduction of the eosinophils, other inflammatory cells, and the submucosal glands was observed after HIFU treatment in group B than that in group A (p<0.05).
Conclusions: A proper increment of HIFU dosage may be recommended to meet the needs of more improvement of AR symptoms and less recurrence.
PMCID: PMC3856383  PMID: 24324369
high intensity focused ultrasound (HIFU); perennial allergic rhinitis (PAR); surgical treatment
25.  Non Allergic Rhinitis: Prevalence, Clinical Profile and Knowledge Gaps in Literature 
Oman Medical Journal  2011;26(6):416-420.
Although Nasal symptoms induced by Non-allergic rhinitis| (NAR) are a cause of wide spread morbidity; the disease is trivialized. There is a lack of Epidemiological studies on the prevalence of non-allergic rhinitis. In spite of being one of the commonest conditions presenting to the General practitioner and otolaryngologists, the clinical profile, diagnosis, and management outcomes are unknown. The objectives of the study were to examine the prevalence and clinical profile of non-allergic rhinitis in Oman. Secondary objective was to identify Knowledge gaps in literature with the aim of directing future research.
A cross sectional study of 610 consecutive adult patients presenting to the Ear, Nose and Throat clinic at Sultan Qaboos University Hospital is presented in this paper. The diagnosis of NAR was mainly based on step wise fashion; including a thorough clinical history and exclusion of other causes of rhinitis; all consecutive patients diagnosed with rhinitis (n=113) had a detailed history, nasal endoscopy, nasal smears, CT scans and an antihistamine response trial. The prevalence of NAR with its clinical profile was subsequently determined. Primary research articles and meta-analysis evaluated for the knowledge gap study were identified through MEDLINE search of English language literature published between 2000-2011.
A total of 610 consecutive patients were studied. The overall prevalence of rhinitis was 18.5% (n=113). The prevalence of NAR was 7.5% (n=46). Cases of allergic rhinitis (5.7%; n=35), Chronic rhinosinusitis (1.8%; n=11), and miscellaneous causes (3.4%; n=21) were excluded. Among the rhinitis population (n=113), the prevalence of NAR was 57% (n=46). The major presenting symptoms included nasal obstruction (93%; n=43), postnasal drainage (78%; n=36), and rhinorrhea (62%; n=29). For the knowledge gap study; 115 Medline titles were reviewed, four systematic reviews, and 34 research papers were reviewed. The text of two recent otolaryngology text books was also reviewed, and the main results of the study revealed the prevalence of NAR had not previously been studied in Oman. Although the recent text now clearly defines NAR, there is scant literature on the prevalence, diagnosis and management outcomes of NAR in the literature.
The study found that more than half of rhinitis patients suffered from NAR. There are no specific diagnostic tests for NAR; a thorough case history is the best diagnostic tool to date. A substantial knowledge gap exists in literature with relations to pathogenesis, clinical and laboratory diagnosis, as well as in reference to medical and surgical outcomes. Larger studies are required and management outcomes need to be studied.
PMCID: PMC3251201  PMID: 22253950
Nasal obstruction; Non allergic rhinitis; Seasonal rhinitis; NANIPER; NARES; Idiopathic rhinitis

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